Endodontic Diagnosis

The purpose of diagnosis is to determine what problem the patient is having,

and why the patient is having that problem. Ultimately, this will directly relate to
what treatment will be necessary. An accurate diagnosis can only result from the
synthesis of scientific knowledge, clinical experience, and common sense. The
process is thus both an art and a science.

Steps of making a diagnosis:

 The patient tells the clinician why the patient is seeking advice.
 The clinician questions the patient about the symptoms and history that led
to the visit.
 The clinician performs objective clinical tests.
 The clinician correlates the objective findings with the subjective details and
creates a tentative differential diagnosis.
 The clinician formulates a definitive diagnosis.

Chief Complaint
 Recording the history of the symptoms begins by making a note of what
prompted the patient to consult a dentist in the first place.
 The form of the notation should be a few simple phrases in the patient's own
words that describe the symptoms causing the discomfort.
 No diagnoses should be included, either by the dentist or by the patient.

Medical History

The clinician is responsible for taking a proper medical history from every patient
and evaluates it in terms of two perspectives:

(I) Medical conditions that might affect the endodontic treatment plan:

 Pregnancy: The second trimester is the safest period during which to

provide routine dental care, however emergency treatment can be provided
anytime. Digital radiography, protective lead aprons and electronic apex
locators can aid minimizing radiation hazards. Oral penicillin and
 Acetaminophen are considered the safest prescriptions.
 Myocardial infarction: A history of a heart attack within the last 6 month
contraindicates elective dental treatment because these patients are
susceptible to repeat infarctions and other cardiovascular complications
during this period.
 Hypertension: The patient should be controlled, we can use local anesthesia
with a vasoconstrictor (maximum permissible dose is 0.04 mg/ml). The non-
steroidal anti- inflammatory drugs used for management of endodontic pain
reduce the effect of anti-hypertensive drugs.
 Diabetes: Clinical data show that a history of diabetes may have a negative
effect on the healing of periapical lesions .The patient should be controlled,
however the healing power of these patients is compromised and they might
need prophylactic antibiotics.
 Patients at risk for Subacute Bacterial Endocarditis: a history of
rheumatic fever, prosthetic heart valves, mitral valve prolapse or a
congenital heart defect necessitates the administration of prophylactic
antibiotics.

(II) Medical conditions with manifestations that mimic dental pathosis.

 Immunocompromised patients and patients with uncontrolled diabetes

mellitus respond poorly to dental treatment and may exhibit recurring
abscesses in the oral cavity that must be differentiated from abscesses of
dental origin.
 Acute maxillary sinusitis is a very common condition that may create
diagnostic confusion since it may mimic tooth pain in the maxillary posterior
quadrant. In this situation the teeth in the quadrant will be extremely
sensitive to cold and percussion, thus mimicking the signs and symptoms of
pulpitis.
 Cardiac angina can elicit pain referred to the left mandible.

(III) Drug History

 It is important to know if the patient is allergic to any drugs. About 5% of
population is allergic to penicillin, and cross reactivity exists between
penicillin and cephalosporins.
 Careful drug history should be obtained. Existing drugs regimens may be
altered for some patients (Immunocompromised, diabetics, or risk for
endocarditis).
Dental History
 The chronology of events that lead up to the chief complaint is recorded as
the dental history. This information will help guide the clinician as to which
diagnostic tests are to be performed.
 The history should include any past and present symptoms, as well as any
procedures or trauma that might have evoked the chief complaint.

History of Present Dental Problem

The dental history is divided into five basic directions of questioning: localization,
beginning, intensity, provocation, and duration.

Localization: “Can you point to the offending tooth?”

 Often the patient can point or “tap” the offending tooth. This is the most
fortunate scenario for the diagnostician because it helps direct the interview
toward the events that might have caused any particular pathosis in this
tooth.
 Additionally, localization allows subsequent diagnostic tests to focus more
on this particular tooth. When the symptoms are not well localized, the
diagnosis is a greater challenge.

Beginning: “When did the symptoms first occur?”

A patient who is having symptoms may remember when these symptoms

started. Sometimes, the patient will even remember the initiating event: it
may be spontaneous in nature, it may have begun after a dental visit for a
restoration, trauma may be the etiology, or biting on a hard object may have
initially produced the symptoms.

Intensity: “How intense is the pain?”

 It often helps to quantify how much pain the patient is actually having. The
clinician might ask, “On a scale from 1 to 10, with 10 the most severe, how
would you rate your symptoms?”
 Hypothetically, a patient could present with “an uncomfortable sensitivity to
cold” or “an annoying pain when chewing” but might rate this “pain” only as
a 2 or a 3.
 These symptoms certainly contrast with the type of symptoms that prevent a
patient from sleeping at night.
Provocation and Relief of Pain: “What produces or reduces the symptoms?”
These provoking and relieving factors may help to determine which diagnostic
tests should be performed to establish a more objective diagnosis.

Duration: “Do the symptoms subside shortly, or do they persist after they are
provoked?”

 The difference between a cold sensitivity that subsides in seconds and one
that subsides in minutes may determine whether a clinician repairs a
defective restoration or provides endodontic treatment.
 The duration of symptoms after a stimulating event should be recorded as to
how long the sensation is felt by the patient, and documented in terms of
seconds or minutes.

With the dental history interview complete, the clinician has a better understanding
of the patient’s chief complaint and can concentrate on making an objective
diagnostic evaluation.

Clinical Examination

Extraoral examination
 Physical limitations may be present, as well as signs of facial asymmetry.
 Palpation allows the practitioner to determine if the swelling is localized or
diffuse, firm or fluctuant.
 Palpation of the cervical and submandibular lymph nodes is an integral part
of the examination protocol. If the nodes are found to be firm and tender
along with facial swelling and an elevated temperature, there is a high
probability that an infection is present.
 Factors affecting the spread of odontogenic infections are Location of root
apex to its overlying buccal or lingual cortical plate, and the relationship of
root apex to the level of muscle attachment.
 Sinus tracts of odontogenic origin may also open through the skin of the
face. These openings in the skin will generally close once the offending
tooth is treated and healing occurs.
 Many patients with extra oral sinus tracts will give a history of being treated
by general physicians and dermatologists with systemic or topical antibiotics
and/or surgical procedures in attempts to heal the extra oral stoma.
Intraoral Examination

Soft tissue examination

 By retracting the tongue and cheek, all of the soft tissue should be examined
for any abnormalities in color or texture.
 Any raised lesions or ulcerations should be documented and, when
necessary, evaluated with a biopsy or referral.

Intraoral swelling

 Intraoral swellings should be visualized and palpated to determine if they are

diffuse or localized and if they are firm or fluctuant.
 These swellings may be present in the attached gingiva, alveolar mucosa,
mucobuccal fold, palate, or sublingually.
 Other testing methods are required to determine if the etiology is
endodontic, periodontal, or a combination of these two or is of non-
odontogenic origin.

Intraoral sinus tracts

 Occasionally a chronic endodontic infection will drain through an intraoral

communication to the gingival surface known as a sinus tract.
 This pathway, which is sometimes lined with epithelium, extends directly
from the source of the infection to a surface opening.
 The term fistula is often inappropriately used to describe this type of
drainage. The fistula by definition is actually an abnormal communication
between two internal organs or a pathway between two epithelium-lined
surfaces.
 Besides providing a channel for the release of infectious exudate and the
subsequent relief of pain, the sinus tract can also provide a useful aid in
determining the source of a given infection.

Radiographic tracing
 Tracing the sinus tract will provide objectivity in diagnosing the location of
the problematic tooth.
 To trace the sinus tract, a size #25 gutta percha cone is threaded into the
opening of the sinus tract; the cone should be inserted until resistance is
felt.
 After a periapical radiograph is exposed, the termination of the sinus tract
is determined by following the path taken by the gutta percha cone.
  This will direct the clinician to which tooth is involved, and more
specifically, which root of that tooth is the source of the pathosis.

Palpation

 Palpation testing uses digital pressure to check for tenderness in the oral
tissues overlying suspected teeth.
 Sensitivity indicates that inflammation in the periodontal ligament
surrounding the affected tooth has spread to the periosteum overlying the
jawbone.
 Additional information about fluctuation or induration of the soft tissues and
changes in the underlying bony architecture can also be detected.
 Because of individual differences, comparing the patient's left and right
sides for similarity or differences.

Percussion

 It is a test for propioceptive receptors present in the periodontal ligament.

 Tenderness noted upon percussion of a tooth indicates some degree of
inflammation in the periodontal ligament.
 This inflammation may be caused by occlusion, trauma, sinusitis,
periodontal disease, or extension of pulpal disease into the periodontal
ligament.
 Percussion is not a test of pulp vitality.
 Before testing, the clinician should communicate the purpose of the test to
the patient and explain how the patient should indicate any tenderness (e.g.,
raising a hand).
 The contralateral tooth should first be tested as a control, as well as several
adjacent teeth that are certain to respond normally.
 Percussion test performed by the handle of the mirror or gently by the index
finger

Mobility
 It is a test for the integrity of the attachment apparatus.
 This integrity is compromised as a result of acute or chronic physical
trauma, occlusal trauma, parafunctional habits, periodontal disease, root
fractures, rapid orthodontic movement, or the extension of pulpal disease,
specifically an infection, into the periodontal ligament space.
  Because determining mobility by simple finger pressure can be visually
subjective, the back ends of two mirror handles should be used, one on the
buccal aspect of the tooth, and one on the lingual aspect of the tooth.
 The degree to which the tooth moves should be recorded as follows:

Grade 1 = less than 1 mm horizontal movement

Grade 2 = 1-2 mm horizontal movement

Grade 3 = more than 2 mm horizontal movement or vertical depressability.

Periodontal Examination

 Periodontal probing is an important part of any intraoral diagnosis. Deep

pocket depths indicate pathologic horizontal or vertical bone loss.
 Periodontal bone loss that is wide and generalized is generally considered to
be of periodontal etiology. However, isolated areas of vertical bone loss may
be of an endodontic etiology, specifically from a non-vital tooth whose
infection has extended from the periapex to the gingival sulcus.
 Furcation bone loss can be secondary to periodontal or pulpal disease. The
amount of furcation bone loss, as observed both clinically and
radiographically, should be documented.
 Deep isolated narrow pockets, highly located or multiple sinus tracts are
suggestive of vertical root fracture.

Pulp Vitality Tests

I. Tests for the neural element of the Pulp:

A) Mechanical tests:

Direct stimulation of exposed dentin with an explorer can elicit a response through
stimulation of the A-Delta sensory fibers of the dental pulp.

B) Thermal tests:

 Cold tests are the primary pulp testing method for many practitioners today.
The most commonly used methods are: ice sticks, Ethyl chloride spray,
Endo Ice (26°C), and frozen carbon dioxide (CO2), also known as “dry ice”
or “carbon dioxide snow”.
 Carbon dioxide has also been found to be effective in evaluating the pulpal
response in teeth with full coverage due to its extremely cold temperature (-
 56°C to -98°C).
 Isolating the teeth individually with a rubber dam and bathing each tooth
with ice water from a syringe for 5 seconds will elicit the most accurate
patient response because it simultaneously cools all surfaces of the teeth.
 Heat Tests include heated instruments, frictional heat, warm sticks of
temporary stopping and the hot water bath. Warm sticks of temporary
stopping are the most convenient for the clinician, but the hot water bath
yields the most accurate response.

Responses to Thermal Tests

The sensory fibers of the pulp transmit only pain whether the pulp has been cooled
or heated. There are four possible responses to thermal stimulation:

1. No response (suggesting a necrotic pulp or a false negative response)

2. Mild-to-moderate degree of awareness of slight pain that subsides within 1 to 2

seconds after the stimulus has been removed (suggesting a normal response)

3. Strong, momentary painful response that subsides within 1 to 2 seconds after the
stimulus has been removed (suggesting reversible inflammation)

4. Moderate-to-strong painful response that lingers for several seconds or longer

after the stimulus has been removed (suggesting irreversible inflammation)

C) Electric Pulp Tests

 The electric pulp tester (EPT) uses electric excitation to stimulate the
sensory fibers within the pulp.
 A positive response to electric pulp testing does not provide any information
about the health or integrity of the pulp; it simply indicates that there are
vital sensory fibers present within the pulp.
 The electric pulp test fails to provide any information about the vascular
supply to the pulp

False responses to EPT

 When a patient reports sensation in a tooth with a necrotic pulp, it is termed
a false positive response.
 Circumstances that can cause false positive responses to electric pulp testing
include patient anxiety, saliva conducting the stimulus to the gingiva,
 metallic restorations conducting the stimulus to the adjacent teeth, and
Liquifactive necrosis conducting the stimulus to the attachment apparatus.
 A false negative response means that although the pulp is vital, the patient
does not indicate that any sensation is felt in the tooth.
 This situation can be produced by premedication with drugs or alcohol,
immature teeth, trauma, poor contact with the tooth, inadequate media,
partial necrosis with vital pulp remaining in the apical portion of the root,
and individual patients with atrophied pulps or high pain thresholds.
 Therefore it is essential that multiple tests be performed before a final
diagnosis is made.

II. Tests for the vascular element of the Pulp:

a) Laser Doppler Flowmetry

 Laser Doppler flowmetry uses a laser beam of known wavelength that is

directed through the crown of the tooth to the blood vessels within the pulp.
 Moving red blood cells cause the of the laser beam to be scattered out of the
tooth.
 This reflected light is detected by a photocell on the tooth surface.

b) Pulse Oximetry
 Another noninvasive method that has been investigated as a method to
determine pulpal blood flow uses a pulse oximeter, which is designed to
measure the oxygen concentration of the blood and the pulse rate.

Special Tests

A- Bite Test

 The tooth may be sensitive to biting when the pulpal pathosis has extended
into the periodontal ligament space, creating a periradicular periodontitis, or
the sensitivity may be present secondary to a crack or fracture in the tooth.
 The practitioner can often differentiate between periradicular periodontitis
and a cracked tooth or fractured cusp using a biting device.
 If periradicular periodontitis is present, the tooth will respond with pain to
percussion and biting tests regardless of where the pressure is applied to the
coronal part of the tooth.
 A cracked tooth or fractured cusp will elicit pain only when the percussion
 or bite test is applied in a certain direction to one cusp or section of the
tooth.
 A variety of devices have been used for bite tests, including cotton
applicators, toothpicks, orangewood sticks, and the Tooth Sloth which allow
for selective biting on each cusp.

B- Selective anesthesia

 Selective anesthesia is most useful to identify which arch has the tooth that
is the source of pain. It is useful in painful teeth, particularly when the
patient cannot isolate the offending tooth even to a specific arch.
 If a mandibular tooth is suspected, a mandibular block will confirm at least
the region if the pain disappears after the injection.
 Individual tooth anesthesia is most effective in the maxilla.
 Anesthesia should be administered in an anterior to posterior direction
because of the distribution of the sensory nerves.

C- Staining and Transillumination

 In order to determine the presence of a crack in the surface of the tooth, the
application of a stain to the area is often of great assistance.
 Shining a very bright light on the surface of the tooth is also very helpful. A
crack blocks the transmission of light.

D- Test Cavity

 This method is used only as a last resort when all other test methods are
deemed impossible or the results of the other tests are inconclusive and
vague.
 An example of a situation where this method might be used is when the
tooth suspected of having pulpal disease has a full coverage crown.

Radiographic Examination and Interpretation

Although a valuable diagnostic tool, radiograph has several limitations.

1. It provides a two-dimensional portrayal of three-dimensional reality.

2. Its interpretation is a learned skill subject to different variations.

3. Cannot be used to determine the status of the health and integrity of the pulp.

4. Radiographic changes from bone loss will not be observed if the bone loss is
only in cancellous bone. However, radiographic evidence of pathosis will be
observed once this bone loss extends to the junction of the cortical and cancellous
bone.

5. Patients with gag reflex, shallow palate or shallow floor of the mouth can
complicate projection

6. Overlap of anatomic structures and misinterpretation of anatomical landmarks

might complicate the interpretation.

Still, valuable information can be obtained from radiographs including:

 Presence of endodontic pathosis:

A widening or break in the lamina dura is the most consistent radiographic finding
when a tooth is non-vital.

Advanced lesions can present as a radiolucent area at the apex or in the area of a
lateral or furcation canal. This radiolucency has a hanging drop of oil appearance
and stays at apex regardless of cone angulation.

 Warning signs of pulp insult:

Presence of caries, fracture, pins, crowns, inlays or onlays, canal or chamber
constrictions all suggest the existence of an exhausted pulp.

 Case difficulty assessment:

The number of roots, root canals, anatomy and curvatures, presence of resorptive
defects or calcifications, evaluating previous treatment, presence of endo-perio
lesions or periapical pathosis.

CBCT

 Low-dose cone beam CT (CBCT) and its observed effectiveness in the field
of dentistry have resulted in the ever-growing usage of this technology in
various endodontic diagnostic procedures.
 CBCT captures a 3D volume of data in a single scan, and the raw data from
each rotation are reconstructed to produce tomographic images.
  The superior accuracy of CBCT imaging may result in the early detection of
periapical lesions and may help to determine their exact locations and
extents.
 CBCT imaging has the potential to become the first choice for endodontic
treatment planning and outcome assessment, especially when new scanners
with lower radiation doses and better resolutions become available.
 However, endodontic cases should be judged individually, and CBCT
imaging should be considered for situations in which information from
conventional imaging systems may not yield adequate amounts of
information to allow for the appropriate management of endodontic
problems.

CLINICAL CLASSIFICATION OF PULP &

PERIAPICAL DISEASES

Normal Pulp
 This is a clinical diagnostic category in which the pulp is symptom-free and
normally responsive to pulp testing.
 Teeth with normal pulp do not usually exhibit any spontaneous symptoms.
The symptoms produced from pulp tests are mild, do not cause the patient
distress, and result in a transient sensation that resolves in seconds.
 Radiographically, there may be varying degrees of pulpal calcification but
no evidence of resorption, caries, or mechanical pulp exposure.
 No endodontic treatment is indicated for these teeth.

Pulpitis
This is a clinical and histologic term denoting inflammation of the dental pulp,
clinically described as reversible or irre- versible and histologically described as
acute, chronic, or hyperplastic

Reversible Pulpitis
 This is a clinical diagnosis based on subjective and objective findings
indicating that the inflammation should resolve and the pulp return to
normal.
 Causative factors include caries, exposed dentin, recent dental treatment, and
defective restorations.
 Conservative removal of the irritant will resolve the symptoms.
 Confusion can occur when there is exposed dentin, without evidence of pulp
pathosis, which can sometimes respond with sharp, quickly reversible pain
 when subjected to thermal, evaporative, tactile, mechanical, osmotic, or
chemical stimuli. This is known as dentin hypersensitivity.
 Exposed dentin in the cervical area of the tooth accounts for most of the
cases diagnosed as dentin sensitivity.

Irreversible Pulpitis
 As the disease state of the pulp progresses, the inflammatory condition of the
pulp can change to irreversible pulpitis.
 At this stage, treatment to remove the diseased pulp will be necessary.
 This condition can be divided into the subcategories of symptomatic and
asymptomatic irreversible pulpitis.

Symptomatic Irreversible Pulpitis

 This is a clinical diagnosis based on subjective and objective findings
indicating that the vital inflamed pulp is incapable of healing.
 Teeth that are classified as having symptomatic irreversible pulpitis exhibit
intermittent or spontaneous pain.
 Rapid exposure to dramatic temperature changes (especially to cold stimuli)
will elicit heightened and prolonged episodes of pain even after the thermal
stimulus has been removed.
 The pain in these cases may be sharp or dull, localized, diffuse, or referred.
 Typically, there are minimal or no changes in the radiographic appearance of
the periradicular bone.
 With advanced irreversible pulpitis, a thickening of the periodontal ligament
may become apparent on the radiograph.
 Evidence of recent or historical pulpal irritation may be present. It may be
seen radiographically or clinically or may be suggested from a complete
dental history.
 Typically, when symptomatic irreversible pulpitis remains untreated, the
pulp will eventually become necrotic.

Asymptomatic Irreversible Pulpitis

 This is a clinical diagnosis based on subjective and objective findings
indicating that the vital inflamed pulp is incapable of healing.
 The patient, however, does not complain of any symptoms.
 Left untreated, the tooth may become symptomatic or the pulp will become
necrotic. Thus endodontic treatment should be performed as soon as
possible.
Pulp Necrosis
 This is a clinical diagnostic category indicating death of the dental pulp.
 The pulp is usually nonresponsive to pulp testing.
 When pulpal necrosis occurs, the pulpal blood supply is nonexistent and the
pulpal nerves are nonfunctional.
 This condition is subsequent to symptomatic or asymptomatic irreversible
pulpitis.
 The necrotic tooth will typically remain asymptomatic until such time when
there is an extension of the disease process into the periradicular tissues.
 With pulp necrosis, the tooth will usually not respond to electric pulp tests or
to cold stimulation. However, if heat is applied for an extended period of
time, the tooth may respond to this stimulus. This response could possibly be
related to remnants of fluid or gases in the pulp canal space expanding and
extending into the periapical tissues.
 Pulpal necrosis may be partial or complete and it may not involve all of the
canals in a multi-rooted tooth. For this reason, the tooth may present with
confusing symptoms.
 After the pulp becomes necrotic, bacterial growth can be sustained within
the canal. When this infection (or its bacterial byproducts) extends into the
periodontal ligament space, the tooth may become symptomatic to
percussion or exhibit spontaneous pain.
 Radiographic changes may occur, ranging from a thickening of the
periodontal ligament space to the appearance of a periapical radiolucent
lesion.

Normal Apical Tissues

 This classification is the standard against which all of the other apical
disease processes are compared.
 In this category the patient is asymptomatic and the tooth responds normally
to percussion and palpation testing.
 The radiograph reveals an intact lamina dura and periodontal ligament space
around all the root apices.

Periodontitis
 This classification refers to an inflammation of the periodontium.
 When located in the periapical tissues it is referred to as apical periodontitis.
 Apical periodontitis can be sub-classified to symptomatic apical
periodontitis and asymptomatic apical periodontitis.
Symptomatic Apical Periodontitis
 This condition is defined as an inflammation, usually of the apical
periodontium, producing clinical symptoms including a painful response to
biting or percussion or palpation.
 It might or might not be associated with an apical radiolucent area.
 This tooth may or may not respond to pulp vitality tests, and the radiograph
or image of the tooth will typically exhibit at least a widened periodontal
ligament space and may or may not show an apical radiolucency associated
with one or all of the roots.

Asymptomatic Apical Periodontitis

 This condition is defined as inflammation and destruction of apical
periodontium that is of pulpal origin.
 This tooth does not usually respond to pulp vitality tests, and the radiograph
or image of the tooth will exhibit an apical radiolucency.
 The tooth is generally not sensitive to biting pressure but may “feel
different” to the patient on percussion.
 Manifestation of persistent apical periodontitis may vary among patients

Acute Apical Abscess

 This condition is defined as an inflammatory reaction to pulpal infection and
necrosis characterized by rapid onset, spontaneous pain, tenderness of the
tooth to pressure, pus formation, and swelling of associated tissues.
 A tooth with an acute apical abscess will be acutely painful to biting
pressure, percussion, and palpation. This tooth will not respond to any pulp
vitality tests and will exhibit varying degrees of mobility.
 The radiograph can exhibit anything from a widened periodontal ligament
space to an apical radiolucency.
 Swelling will be present intra-orally and the facial tissues adjacent to the
tooth will almost always present with some degree of swelling.
 The patient will frequently be febrile, and the cervical and submandibular
lymph nodes may exhibit tenderness to palpation.

Chronic Apical Abscess

 This condition is defined as an inflammatory reaction to pulpal infection and
necrosis characterized by gradual onset, little or no discomfort, and the
intermittent discharge of pus through an associated sinus tract.
 In general, a tooth with a chronic apical abscess will not present with
clinical symptoms. The tooth will not respond to pulp vitality tests, and the
radiograph or image will exhibit an apical radiolucency.
 Usually the tooth is not sensitive to biting pressure but can “feel different” to
the patient on percussion.
 This entity is distinguished from asymptomatic apical periodontitis because
it will exhibit intermittent drainage through an associated sinus tract.